Large for Dates Pregnancy (Diabetes) Flashcards
What is gestational diabetes?
Carbohydrate intolerance resulting in hyperglycaemia of variable severity with onset or first recognition in pregnancy
Complications of diabetes in pregnancy are always related to what?
Poor diabetic control
What are some complications of diabetes in pregnancy which are specific to pre-existing diabetes?
Miscarriage, intra-uterine death and congenital anomalies
What are some complications of diabetes in pregnancy which can be seen with both pre-existing and gestational diabetes?
Pre-eclampsia, polyhydramnios, macrosomia, shoulder dystocia and neonatal hypoglycaemia
What is the demographic of mothers who have type 1 diabetes?
Young, white, slim
What is the demographic of mothers who have type 2 diabetes?
Older, overweight, Asian/Caribbean/African
What are the 4 main things to discuss at pre-pregnancy counselling for those with pre-existing diabetes?
HbA1c control, stopping embryopathic medications, determining any current micro or macrovascular complications, start taking folic acid
Before getting pregnant, mothers with diabetes should aim for an HbA1c of what? Pregnancy should be avoided if there is an HbA1c of what?
48mmol/mol / > 86mmol/mol
What medications must women with diabetes stop taking before getting pregnant? What could be a replacement option?
ACE inhibitors and statins - could replace with labetalol
Describe how folic acid should be taken in women with pre-existing diabetes?
5mg 3 months before conception until 12 weeks gestation
What medication should women with pre-existing diabetes take from 12 weeks gestation until delivery?
Low dose (75mg) aspirin daily
Women with pre-existing diabetes should undergo regular screening throughout pregnancy for which complication?
Retinopathy
What hypoglycaemic agents can be used during pregnancy?
Insulin and metformin
When should women with diabetes (pre-existing and gestational) receive growth scans?
Every 4 weeks from 28 weeks onwards
When should a baby of a pre-existing diabetic mother be delivered, providing there are no complications? Why is this done?
38 weeks, to reduce the risk of late stillbirth
What are some risk factors for gestational diabetes?
Previous GD, previous macrosomic baby, diabetes in a 1st degree family member, South Asian/Caribbean ethnicity, BMI > 30
When is screening for gestational diabetes carried out?
At 24-28 weeks, if risk factors are present
Describe briefly the pathophysiology of gestational diabetes?
Placental hormones such as hPL, cortisol and growth hormone promote insulin resistance. To maintain stable glucose levels, the normal response to this would be to produce more insulin, however this does not happen in gestational diabetes and so the woman becomes hyperglycaemic.
Why do babies of diabetic mothers become macrosomic?
Because there is overgrowth of insulin sensitive tissues
Describe what happens after a baby with a diabetic mother is born?
These babies are used to having high glucose levels, so they have a high basal rate of insulin. Once they are born, the maternal source of glucose is taken away and so they become hypoglycaemic. This leads to hypoxia which triggers erythropoiesis, polycythaemia and eventually jaundice.
Foetal metabolic reprogramming seen in babies of diabetic mothers can have what long term consequences?
Increased risk of obesity, insulin resistance and diabetes in the future
If there has been a previous episode of gestational diabetes, what is the chance of this recurring? What is different about testing women who have had gestational diabetes previously?
> 50% / these women receive an oral glucose tolerance test at booking, and if this is negative then they get tested again at 24-28 weeks. They can also monitor their own blood glucose levels early in a pregnancy.
Describe how the oral glucose tolerance test is done?
The woman will undergo an overnight fast, her fasting blood glucose levels will be measured and then she will drink a solution containing 75g of glucose and then after 2 hours her glucose levels will be measured again
A fasting blood glucose of what is diagnostic of gestational diabetes? A 2 hour blood glucose of what is diagnostic of gestational diabetes?
5.1mmol/l + / 8.5mmol/l +
Having gestational diabetes increases a woman’s risk of developing what later in life?
70% risk of developing type 2 diabetes
How often should blood sugar be monitored in women with gestational diabetes? When?
4 times a day, before each meal and before bed
In gestational diabetes, what is a normal a) fasting glucose? b) hour after eating glucose?
a) 3.5-5.5mmol/l b) < 7.8mmol/l
How are 80-90% of cases of gestational diabetes managed?
By diet, exercise and weight control
When should the use of hypoglycaemic agents be considered in the treatment of gestational diabetes?
If diet and exercise are failing to maintain blood glucose levels, or if the baby is macrosomic on US
What are the advantages of using an oral hypoglycaemic agent for gestational diabetes?
Avoidance of hypoglycaemia, less weight gain and easier to use
When should short acting insulin be taken? When should long acting insulin be taken?
Before meals / before bed
Does insulin cross the placenta? What is the risk of treating gestational diabetes with insulin?
No / hypoglycaemia
When should a mother with gestational diabetes deliver her baby if a) managed with insulin? b) managed with metformin? c) managed with diet alone?
a) 38 weeks b) 39-40 weeks c) 40-41 weeks
When should a mother with gestational diabetes deliver earlier than 38 weeks?
If there is foetal macrosomia, IUGR or PET
When should a C-section always be used in gestational diabetes?
If the baby is macrosomic i.e. > 4.5kg
What happens in terms of treatment for diabetes (both pre-existing and gestational) following delivery of a baby?
Pre-existing will go back to previous treatment regime and gestational will stop all medications
What are the main risk factors for developing type 2 diabetes following an episode of gestational diabetes?
Obesity, use of insulin, impaired glucose tolerance post-partum and ethnicity
Following delivery after an episode of gestational diabetes, what follow up is required?
OGTT 6-8 weeks after deliver, and annual HbA1c measurements
